COPD Assessment

Section

COPD Review

Please only complete the following questionnaire if requested by your GP practice as part of your routine COPD review.

This questionnaire is for a routine review of your COPD symptoms. If you are experiencing shortness of breath, please follow your care plan (if you have one) or ring your GP or 999 immediately.

Please select the best description of your cough from the list below: *

No cough

Dry cough

Productive cough - clear sputum

Productive cough - green sputum

Productive cough - yellow sputum

Sputum appearance - frothy/watery

Unable to cough up sputum

Please select the best description of your symptoms at night: *

No cough

Cough

Cough and wheeze

Difficulty breathing (breathlessness/shortness of breath)

Please select the best description of your breathing at night: *

No breathlessness (normal breathing)

Breathlessness when lying flat

Severe breathlessness that wakes you up

Please select any symptoms of swelling (oedema) that apply to you:

Please select the answer that best describes your breathing: *

I am short of breath only on strenuous exercise

I am short of breath when hurrying or walking up a slight hill

I walk slower than contemporaries (peers) on level ground due to the breathlessness or stop if walking at my own slow pace

I stop breath after walking 100 yards or after a few minutes on level ground

I am breathless when dressing or am too breathless to leave the house

How many COPD exacerbations (attack) have you had in the past? *

How many hospital admissions have you had due to your COPD in the past year? *

Inhaler Technique

It is essential to have a good inhaler technique to ensure that your medication gets to the part of your lungs that need it. Please watch the specific inhaler video below to check that you are using your inhalers correctly:

COPD Foundation: Inhlaer Technique Videos

I have watched the above relevant inhaler technique videos and am happy with my inhaler technique: *

Yes

No

Lifestyle - Alcohol

How often do you have a drink containing alcohol? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Lifestyle - Smoking

Do you smoke? *

Never smoked

Ex-smoker

Trivial smoker (less than 1 cigarette per day)

Light smoker (1-9 cigarettes per day)

Heavy smoker (20-39 cigarettes per day)

Very heavy smoker (40 or more cigarettes per day)

Do you use an e-cigarette? *

No

Ex-User

Yes

Would you like help to quit smoking? *

Yes

No

For further information, please visit www.nhs.uk/better-health/quit-smoking

Coughing

I never cough

I cough all the time

Phlegm

I have no phlegm (mucus) in my chest at all

My chest is full of phlegm (mucus)

Tightness

My chest does not feel tight at all

My chest feels very tight

Stairs

When I walk up a hill or one flight of stairs I am not breathless

Stairs: from 0 (When I walk up a hill or one flight of stairs I am not breathless) to 5 (When I walk up a hill or one flight of stairs I am very breathless) *

When I walk up a hill or one flight of stairs I am very breathless

Activities

I am not limited doing any activities at home

Activities: from 0 (I am not limited doing any activities at home) to 5 (I am very limited doing any activities at home) *

I am very limited doing any activities at home

Leaving

I am confident leaving my home despite my lung condition

Leaving: from 0 (I am confident leaving my home despite my lung condition) to 5 (I am not at all confident leaving my home because of my lung condition) *

I am not at all confident leaving my home because of my lung condition

Sleep

I sleep soundly

I don't sleep soundly because of my lung condition

Energy

I have lots of energy

I have no energy at all

Further Questions

I have the following questions that I would like to raise with my COPD Nurse or Doctor:

Please see the following links for further information on COPD that you may find useful:

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COPD Assessment

COPD Assessment

Section

COPD Review

Inhaler Technique

Lifestyle - Alcohol

Lifestyle - Smoking

COPD Assessment

Coughing

Phlegm

Tightness

Stairs

Activities

Leaving

Sleep

Energy

Further Questions

Hay Fever